Number of dentists registered in the UK in 2007: 131 in 2008: 128 in 2009: 127 in 2010: 127 in 2011: 131

Background

The number of registered dentists in Denmark has remained stable over the last decade. However, a forecast by the Danish Health and Medicines Authority (DHMA), 2010 predicted that the number of dentists will decrease continuously by around 70 dentists a year until 2025 mainly because of retirement of a large number of older dentists. There are no data on dentists qualified overseas but there is little movement of dentists in and out of Denmark. The percentage of female dentists is 60 per cent. About 68 per cent of the dentists in Denmark work in private practice (5).

Denmark has a highly decentralised National Health Service, largely funded by general taxation. Oral healthcare (including orthodontics) is free for children from 0 to18 years of age and subsidised for adults. Approximately 1,000 dentists work within the municipal dental care sector (public dental service) treating children, adolescents and people with special care dental needs. Dental care is usually delivered in municipal school dental clinics, by salaried public dentists. It is estimated that 99 per cent of children and adolescents utilise the service each year. Most adults obtain oral healthcare from the private sector. A proportion of the cost of this care is refunded by the public health insurance scheme financed by the government. In response to improving oral health in the population and changing patterns of treatment needs, the DHMA estimates an increased need for dental hygienists in the future.
There is a well-developed system employing dental auxiliaries in which dental hygienists, clinical dental technicians and dental nurses provide clinical support for dentists (5).

The DHMA administers initial registration and maintains a national register of dentists. (http://www.sst.dk/DS/OpslagAutReg.aspx)

In order to be a principal in private practice and receive government payments, dentists must also register with the regional branch of the Danish Dental Association (DDA) and with the DHMA who certify that he/she has worked as an employed dentist for 1440 hours.

Dentists who work in the public dental service are not required to register with the DDA. Directors of public clinics must be authorised by the DHMA.

All dentists qualified outside the EEA are required to take additional dental courses prior to registration in Denmark.

Dental practices can be rented or owned and there is no state assistance for establishing a dental practice.

Hepatitis B vaccination is not compulsory in Denmark.

Professional liability insurance is provided by the DDA and is compulsory for private dental practitioners. This only covers dentists in Denmark.

It is mandatory for undergraduate dental students to take training in ionising radiation protection. Continuing education in ionising radiation is not mandatory. All new X-ray equipment must be registered by the DHMA.

Only approved companies are allowed to collect amalgam. The dentist must have written documentation for its disposal.

2. Education and training

There are two dental schools in Denmark. Dental education is state-funded and lasts for five years.

After graduation students obtain an authorization as a dentist issued by the DHMA which allows them to work as employed dentists, but if one wishes to own a practice, he/she needs to have a permission from the DHMA to practise independently. This can be obtained if the dentist has worked for at least 1,440 hours after qualifying. The dentist must have treated adult patients and children for at least 360 hours. There is no registration fee, but to practise independently the dentist must pay approximately 147 Euros to the DHMA (2010).

To undertake specialist training a graduate must have had at least two years’ post qualification work experience. Trainees are paid by the hospital or dental school.

There is formal training in two specialties: orthodontics and oral surgery.

The training for specialists in oral surgery lasts for five years and three years for orthodontics.

3. Support systems

There are two federations or trade unions for dentists in Denmark, DDA and the Public Dentists Group.

The main goals of the two trade unions are: to look after the interests of all dentists in all aspects of the profession, to promote oral health within the Danish society and to develop all aspects of dental care for the Danish population.

4. The dental team

Dental hygienists undertake three years training at The School for Dental Nurses and Dental Hygienists.

After graduation dental hygiene students obtain an authorization as a dental hygienist issued by the DHMA which allows them to work independently or as an employed dental hygienist.

Training for dental technicians is two years in a school for dental technicians. They work mostly in laboratories, hospitals or dental faculties and are salaried. Some are employed by dentists in private dental practice.

Dental nurses’ training is carried out at a School for Dental Nurses and Dental Hygienists and or in technical schools which exist in several municipalities.

Clinical dental technicians/denturists undertake a four-year training course at a dental technician school. They need a licence from the DHMA to practise independently. They provide full dentures without the patient being seen first by a dentist. For partial dentures, a treatment plan from a dentist is required. A patient with pathological changes must be referred to a dentist.

5. Dental care delivery

Dental services for children aged 0 to 18 years are organised by the municipalities and are free of charge. This includes orthodontic treatment. Since January 2004, children can choose to receive dental care from a private practitioner instead of the public service but they have to pay 35 per cent of the costs. At the age of 16 years, children may change to a private dentist with the full cost of treatment still being met by municipalities until they are 18 years old.

The dental service for adults is operated by an agreement between the regions and the DDA. Patients pay 30 to 65 per cent of the cost of their fees depending on the patient’s age and the treatment. The cost is refunded by the public health insurance scheme, financed by the government out of general taxation.

The subsidy is higher for preventive care and essential treatments. Subsidies for 18 to 25-year-olds are also higher. The treatment subsidies include examination and diagnosis, restorations, oral surgery, periodontology, and endodontics. For adults, orthodontics, crowns and bridges and removable prosthodontics have to be paid for in full by the patient.

People with social security or unemployment benefits, such as the homeless or victims of drug and alcohol abuse, usually receive free dental care after prior approval from the municipality where they live.

The Danish counties offer highly specialised care and treatment for patients with rare diseases or special needs for whom the underlying condition leads to special oral problems.

The provision of dental care for the elderly living in nursing homes and for those with special needs living in their own homes but who are not able to use the normal dental care system, is now one of the roles of the municipal dental care service.

It is mandatory to make public the price list of the treatments not covered by the state scheme. Dental fees are defined in a departmental order, with suggestions from the Danish Regional authorities and the DDA to the government.

Dentists who work in hospitals are mostly oral surgeons.

Dentists working in university dental faculties not only have teaching responsibilities but also have to treat patients in university clinics, undertake research, or have a mixture of management, research and student supervisory responsibilities. Dental teachers usually work part-time and spend their remaining time in practice.

6. Quality Assurance mechanisms

Continuing education is not mandatory for dentists. However, in 2009 the DDA started a voluntary scheme which requires its members to complete 25 hours of registered CPD per year. This does not apply to dentists who work in the public dental service (5). The County Dental Society of the region monitors standards of oral health service through auditing the treatment figures which every dentist has to submit in order to claim public subsidy. Any dentist who carries out particular treatments by approximately more than 40 per cent of the regional average has to provide an explanation.

Monitoring the standards of private dental practice is the responsibility of the Society of the five regional bodies and the DDA. Monitoring consists of statistical checks and official procedures for dealing with patient complaints.

There are two systems for dealing with complaints. One relates to complaints against dentists working with ’the agreement of adult dental care’ and the National Agency for Patients’ Rights and Complaints deals with complaints about other dentists and auxiliaries.

A complaint system is managed in the regions by regional politicians and members of the DDA. The sanctions can vary from a reprimand to a recommendation to the DHMA to take away the authorisation to practise. The decisions can be appealed to a national committee.

Key Points to Consider When Inducting or Supporting a Dentist Qualified in Denmark

Dentists qualified in Denmark :

Probably have considerable experience of a publicly funded health service;

May not appreciate that professional indemnity is not provided by the Dental Association in the UK;

May not appreciate that hepatitis B vaccination is compulsory in the UK;

May not appreciate that continuing professional education is a requirement for continuing dental registration in the UK and to work in public dental practice;

If they have graduated in the last ten years, will not have undertaken vocational or foundation training in Denmark;

May not appreciate that clinical dental technicians are able to see patients for complete dentures without a referral by a dentist;

Are likely to have experience of working with a dental hygienist, who may be able to work independently and to provide basic diagnostic tests and administer local anaesthetic;

May have little experience of working in 100 per cent private dental practices.

Country : France

(not fully updated at 30 April 2012)

Population : 65,075,300 (2011)

Number of registered dentists: 44,537 (2008)

Number of dentists in active practice: 40,968 (2008)

Number qualified overseas: 660 (2008)

Number of dentists registered in the UK in 2007: 82 in 2008: 82 in 2009: 78 in 2010: 82

Background

In 2008, there were 44,537 registered dentists and 40,968 in active practice and 37 per cent of dentists were female (5). Oral health care is predominantly private in France (91 per cent of provision). A mandatory insurance system called "Sécurité Sociale" (Social Security) covers the entire population. The "Sécurité Sociale" was set up in 1945/1946 with two main objectives (10):

• To compensate patients for loss of income due to illness;

• To allow entitled persons to cover the medical or paramedical expenses resulting from their own illness or from the illness of any members of their dependent family.
Most oral healthcare is provided by independent practitioners in accordance with an agreement known as the Convention, and almost all dentists (99 per cent) in France practice within this system. Where a dentist does not work within the Convention, then the patient cannot reclaim the fees paid for treatment. All legal French residents are entitled to treatment under the Convention (5). Patients pay full fees to the dentist. There are many private dental insurance schemes and approximately 90 per cent of the population utilise complementary insurance schemes, either by voluntary membership or through the Convention to cover all, or part of their treatment (5).
Professional liability insurance has been compulsory for all dentists since March 2002.
The Ordre National des Chirurgiens-Dentistes manages the registration of dentists in France. It stipulates an Ethical Code which defines the contract with the patient, consent and confidentiality, continuing education, relationships and behaviour between dental surgeons and advertising (10).

Glossary of Terms

Stomatologist

Stomatologists are medical doctors who have specialised in stomatological sciences. The professional title is: “Médecin spécialiste qualifié en stomatologie”. This is considered a medical specialty. They can undertake the same treatment as qualified dentists, as well as maxillofacial procedures. The duration of their training is six years (medical training) followed by four years of specialist internship. They then obtain a diploma of “Doctor in Medicine” as well as a diploma of qualification (DES Diploma of Specialised Studies).

Summary of relevant points

1. Regulatory Mechanisms

The Ordre National des Chirurgiens-Dentistes manages the registration of dentists in France. The register of dentists is held primarily by Departmental (Regional) Dental Councils, but a national register also exists. The cost of registration in 2008 was 354 Euros and practitioners are required to pay an annual charge in order to remain on the register.

The Ordre National des Chirurgiens-Dentistes is applicable to all dental practitioners in France (departments and overseas territories included). The Ethical Code covers the contract with the patient, consent and confidentiality, continuing education, relationships and behaviour between dental surgeons and advertising.

Vaccination against hepatitis B, diphtheria, tetanus, and poliomyelitis is a mandatory requirement, as stipulated by a Health General Regulation.

Liability insurance has been compulsory for all health professions since March 2002. For Confédération Nationale des Syndicats Dentaires (CNSD) members, it is included as a part of the association membership fee. Insurance companies can also provide professional civil liability cover for a dentist’s patients during their working life. This insurance does not cover dentists for working abroad, except for a maximum duration of two months in EU countries (including Andorra and Switzerland for temporary practice, or for dentists migrating and acquiring new insurance).

Dentists may run practices as corporates, either on their own or in association with others. However, a non-dentist cannot be a part, or full owner of a practice, (except in the case of an incorporated practice), where a legal successor of a dead dentist can inherit the practice for five years

Training in radiation protection is now part of the undergraduate curriculum. Equipment must be registered with the Institut de Radioprotection et de Sureté Nucléaire, and the registration is valid for five years. New rules governing Radiation Protection Supervisors have recently been implemented.

The use of amalgam separators is mandatory.

There are no rules limiting the size of a dental practice in terms of the number of associate dentists or other staff. Dentists can work on their own, and in association, or with, an assistant-dentist. But a dentist may only employ one assistant-dentist. Premises may be rented or owned. Generally recent dental graduates buy the practice of a retiring dentist.

There is no post qualification vocational training, nor Foundation Training Programme in existence in France

Orthodontics is the only recognised dental specialty in France

There is no referral system in France for access to specialists – patients self-refer to a specialist directly.

The Ordre, University and other professional organisations (including CNSD) have agreed to introduce the specialty of Oral Surgery as soon as legislation permits this.

Oral Maxillo-facial surgery is considered a medical specialty.

3. Support Systems

The main professional union for dental surgeons is the Confédération Nationale des Syndicats Dentaires (CNSD), encapsulating 100 departmental unions, and representing approximately 50 per cent of the practicing dentists in France. The Union works alongside the government in planning national oral healthcare services, and also partners the Social Security Caisses (Health insurance funds), and is recognised as the representative union by the public authorities.

The French Dental Association (ADF), founded in 1970, represents the entire dental profession in France (general dental practitioners, surgeons, specialists, academics, hospital, individual members of professional unions, scientific societies etc).

4. The Dental Team

In France no auxiliaries are permitted to work in the mouth. The only recognised auxiliary personnel are dental chair-side assistants, receptionists and dental technicians.

Many dentists work without full-time chair side support from a dental assistant (5,10).

5. Dental care delivery

A mandatory insurance system known as "Sécurité Sociale" (Social Security) covers the entire population. Patients pay full fees to the dentist and the "Sécurité Sociale" reimburses about 70 per cent of these fees on a fee-per-item basis. This includes treatments such as extractions, restorative dentistry, prosthetics and orthodontics (if the treatment begins before the age of 16 years). Scaling, sealing and fluoride tablet administration are also reimbursed in the same way as preventive treatments (10). Children and teenagers aged 6, 9, 12, 15 and 18 are entitled to an annual examination which is fully covered by health insurance.

The cost of the examination is directly paid to the dentist. Restorative treatment, as well as preventive measures such as fissure sealants, are also free. For other treatments e.g. orthodontics and prosthetics, dentists may set their own fees, after informing the patient of the estimated cost. Most prosthetic treatment is paid for entirely by patients, who may take out additional private insurance to cover part, or all, of such costs. 76 per cent of the population does this. A proportion of these fees are usually covered by the social security system on the basis of a fee scale, subject to prior approval. The patient pays the full fee to the dentist and is then issued with a form which is used to reclaim the relevant amount. There is no restriction on how often treatment can be undertaken.

A Universal Sickness Insurance (CMU) was created on 1st January 2000 to enhance access to care for the more vulnerable members of the population. Practitioners are directly paid by Social Security and complementary insurance. The fees for restorative and surgical care are defined in the Convention (annual contract between the dentists and the health fund). About five per cent of the population belonging either to low income groups or to groups without any income, benefit from this free care

For prosthetic dentistry there is an alternative scale of fees which have not been reviewed since their creation on 1st January 2000.

Domiciliary care can be provided on request, by a limited number of patients, such as those ill or disabled. Once requested, a dentist must provide this care.

Most oral healthcare is provided by general dental practitioners in accordance with an agreement known as the Convention and almost all dentists (98 per cent) practise within the Convention.

Oral health care is predominantly private in France. There are many private dental insurance schemes and approximately 90 per cent of the population utilize complementary insurance schemes, either by voluntary membership or through the CMU to cover all, or part of their treatment.